Ketamine has been used for decades as an anesthetic agent. Over the past several years, its effectiveness in the treatment of treatment resistant depression has become well known. It is the only IV agent that has ever shown benefit in the treatment of depression. Because it is broken down in the gut to an ineffective agent, it can only be used intravenously. Because of this pharmaceutical companies have come out with a new ‘version’ of ketamine that can be absorbed through the nasal mucosa and so esketamine (cousin of Ketamine) was born. This is know as Spravato. We do offer both intravenous and Spravato to patients who meet the criteria for treatment resistance.